2.0 Analysis 2.1 Introduction The flight crew was certified and qualified for the flight, and the aircraft was complete, intact, and functioning normally before it struck the trees. Consequently, the analysis will deal with the following factors: weather information, crew decision making and resource management, and spatial disorientation. 2.2 Weather Information The current weather information for Peterborough Airport was relayed to the flight crew by the Toronto ACC controller when the initial approach clearance was given at 2214. The AWOS reported ceiling at this time was 300feet overcast, but, as reported on special reports before and after the occurrence, this ceiling was fluctuating between 300 and 500 feet, with good visibility. This explains why, on the initial approach, the aircraft could not be seen from the ground, but could be heard when it flew over the airport at 1200 feet asl (575 feet above ground level (agl)). 2.3 Crew Decision Making and Resource Management In accordance with the approach briefing, the flight crew conducted the published missed approach when the initial approach was unsuccessful. During the second approach, the aircraft was south of the approach track, and it was necessary for the captain to manoeuvre the aircraft to align it on runway 09. The aircraft attitudes during this manoeuvring, and the point where the aircraft touched down on the runway, indicate that during the second approach the aircraft was never positioned properly for the flight crew to attempt a landing and that a second missed approach would have been prudent. The continuance of this unstabilized approach to landing was contrary to company SOPs and FAR 91.175(c)(1). As the aircraft touched down near the runway midpoint, the captain elected to abort the landing, because there was insufficient runway remaining. The first officer was expecting the captain to proceed with another published missed approach at this point; however, the captain flew a left visual circuit reportedly at circling approach altitude of 1300feet asl (672 feet agl). Based on the AWOS weather reports, the ceiling at the time of the accident was at 400feet agl. It is unlikely that this circling altitude was ever captured for the visual circuit; the aircraft would likely have been in cloud. The first officer did not challenge the captain when he realized that the aircraft was not proceeding as they had previously briefed. Due to the close proximity of the left circuit to runway 09, it was necessary for the aircraft to be flown in one continuous turn from downwind leg to final leg. The first officer, seated in the left seat, scanned the outside environment while the captain scanned the flight instruments and the outside environment. During the turn onto final leg, the first officer observed the PAPI and advised the captain that the aircraft was too low. When the captain expressed that he wanted to go lower, the first officer was confused and, again, did not challenge the captain. When the captain saw that the PAPI was indicating that the altitude was too low, he initiated a missed approach. In-house crew resource management (CRM) training has been, and is being, provided to the flight crews by the company. Although this was a training flight and the first flight that this particular flight crew had conducted together, basic procedures__such as the completion of checklists and setting of altimeters to the appropriate altimeter setting__were contrary to company SOPs. This breach of company SOPs and the lack of crew coordination/challenge that existed after the aborted landing indicate a need for enhanced CRM. 2.4 Spatial Disorientation The aircraft was operating in a dark IMC environment with limited visual cues to the airport. During the missed approach from the third attempt to land at Peterborough Airport, the captain applied full power to the aircraft. It is likely that the captain misinterpreted the acceleration forces to which he was subjected and, as a result of inadequate monitoring of the flight instruments, the aircraft banked left and pitched nose-down. Tree cuts indicated that the aircraft was in an approximate 45-degree, left-banked attitude at impact. The ground scarring indicates that, at the point of ground impact, the aircraft pitch attitude had changed to nose-up. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The captain's attempt to continue the landing during the second approach was contrary to company standard operating procedures and Federal Aviation Regulations, in that the approach was unstable and the aircraft was not in a position to land safely. Following the aborted landing, the flight crew proceeded to conduct a circling approach to runway 09, rather than the missed approach procedure as briefed. The pilot lost situational awareness during the overshoot after the third failed attempt to land, likely when he was subjected to somatogravic illusion. Breakdown in crew coordination after the aborted landing, lack of planning and briefing for the subsequent approach, operating in a dark, instrument meteorological conditions environment with limited visual cues, and inadequate monitoring of flight instruments contributed to the loss of situational awareness. 4.0 Safety Action 4.1 Action Taken Following this occurrence, the company directed its flight operations department to develop a list of restricted airports where inclement weather and/or aircrew experience may present unacceptable risk factors. The company further directed Falcon aircraft crews that cross-cockpit manoeuvring(3) is not acceptable in airport terminal areas when weather is below visual flight rules minimums. The company provided the following direction to all aircrews: Clarification that an instrument flight rules clearance for a straight-in approach does not constitute a clearance for a circling manoeuvre unless specifically authorized by air traffic control (ATC). If weather or execution of approach procedures precludes landing after two attempts, a third approach procedure shall not be executed until the weather improves. Crews shall execute the published missed approach, enter holding, or divert to the alternate airport, as directed by ATC. This does not preclude a third or subsequent approach procedure if the published missed approach or balked landing was due to airport traffic or other runway obstacle. Review the process for calculation of a visual descent point (VDP) or calculated descent point (CDP). This applies only to straight-in non-precision approaches. If the VDP/CDP is reached and the airfield is not in sight or the aircraft is not in a position to begin a descent to land, missed approach procedures must be initiated, unless specifically cleared by ATC for alternate procedures. The company directed its director of training to coordinate with Flight Safety International or SimuFlite for an on-site cockpit/crew resource management course. Subsequent courses will be developed by the company training department for inclusion into initial and recurring training programs.